Rapid fluctuations in conscious state in a patient with an extensive spinal dural fistula

Complication Avoidance in Spine Surgery

The outcomes of spine surgery are closely related to postoperative morbidity. Therefore, an experienced surgeon must be aware of various complications and should apply all necessary preventive measures to avoid them. It is widely considered that complications of spine surgery are underreported and that their real incidence is much higher than expected. This review highlights methods to prevent various types of morbidity that may be encountered during different spinal procedures, considering general complications, approach-related complications, fusion- and implant-related complications, and systemic complications.

Management of patients with spontaneous intracranial hypotension causing altered level of consciousness: report of two cases and review of literature

BACKGROUND

Decreased level of consciousness is a rare neurological manifestation of spontaneous intracranial hypotension (SIH), which typically presents with orthostatic headache. The optimal management of this uncommon presentation remains uncertain.

METHODS

We analyzed the presentation, management and outcome of two patients in our institution and reviewed 22 patients reported in the literature with SIH and decreased level of consciousness, defined as any decrease in the patient's Glasgow Coma Scale score.

RESULTS

There were 20 male and four female patients (M:F ratio of 5:1) with an average age of 52 years (range 37 to 68 years). There was a variable time interval of up to many months between the initial presentation of SIH and changes in the level of consciousness. An epidural autologous blood patch was eventually successful in 79% of the patients, although up to three trials were necessary in seven of these patients. Intrathecal saline infusion used as a temporizing measure resulted in excellent response within hours in five out of six patients who received this treatment. Drainage of the subdural collection either did not result in any sustained improvement or resulted in clinical deterioration in 12 out of 12 patients who received this treatment.

CONCLUSIONS

In the absence of a clinical trial because of the rarity of this entity, the treatment of SIH complicated by decreased level of consciousness remained controversial in the past. However, current collective experience supports early treatment of patients with SIH and decreased level of consciousness with one or more epidural blood patches. Fibrin glue and surgical duroplasty are the next steps in the management of patients in whom epidural blood patches fail. Drainage of the subdural collections may be detrimental.